peri-operative care (D&C and CS)

• A Preoperative checklist is a hospital form accomplished by nurses prior to surgery that includes key safety checks as outlined in the World Health Organization (WHO) Surgical Safety Checklist and The Joint Commission Universal Protocol
• Preoperative checklist

  • It is designed for use in all types of facilities (eg, hospital ORs, ambulatory surgery settings, physician offices)
  • It should be completed as required per surgery to reduce possible errors in patients scheduled for surgery and admitted to the operating room
• Information gathered in preoperative checklist

  • Current medical diagnosis
  • Diagnostic and laboratory tests results
  • Physical status and physiological response to surgery
  • Cardiopulmonary Clearance
  • Spiritual needs, ethnic and cultural background
  • Previous surgery
  • Psychosocial status
• Cardiopulmonary Clearance

  A form which contains remarks of cardiologist and pulmonologist regarding patient's risk to intraoperative and postoperative complications based on their physical assessment, history taking and laboratory and diagnostic tests results of the patient
• Cardiopulmonary Clearance risk levels

  • High risk
  • Moderate risk
  • Low risk
  • No contraindication
• Informed Consent

  1. Obtaining operative consent is the primary health care provider's responsibility

  2. The nurse should make sure that the informed consent is signed before sending the client for the procedure

  3. The nurse may be asked to witness a woman's signature on such a form

  4. In the Philippines, a person 18-60 years old qualifies to be considered of legal age and can sign the consent

  5. If the client is a minor, then the parent or legal guardian will sign the consent
• Overall Hygiene

  1. Provide a clean hospital gown on admission

  2. If a woman's hair is long, encourage her to braid it or put it into a ponytail

  3. Follow institution's procedures with regard to removing nail polish, jewelry, contact lenses, lip or mouth piercings, or hair ornaments before surgery

  4. Ensure that the woman's toenails are free of polish if she wears acrylic fingernails
• Gastrointestinal Tract Preparation

  1. A gastric emptying agent, such as metoclopramide (Reglan), to speed stomach emptying or a histamine blocker, such as ranitidine (Zantac), to decrease stomach secretions may be prescribed prior to surgery

  2. An oral antacid such as citric acid and sodium citrate (Bicitra), which acts to neutralize acid stomach secretions may be prescribed
• Baseline Intake and Output Determinations

  1. An indwelling urinary catheter may be prescribed to reduce bladder size and keep the bladder away from the surgical field

  2. Be certain urine drains freely and keep the drainage bag below the level of the woman's bladder

  3. Do not traumatize the urethra by repeated attempts as catheterization can be done in the operating room (OR) after the anesthetic agent is given

  4. Mark the level of drainage in the bag just before surgery or empty it, so that pre-surgery urine output can be differentiated from post-surgery urine output
• Hydration

  1. Most women have an IV fluid line begun before surgery

  2. Use a large-size catheter or needle (18 or 20 gauge), so that blood replacement therapy can be administered by the same line if needed
• Preoperative Medication


  A minimum of preoperative medication is used with a woman having a cesarean birth to prevent compromising the fetal blood supply and to ensure that the newborn is wide awake at birth and can initiate respirations spontaneously
• Transport to Surgery

  1. A woman may be transferred to surgery in her bed, or she may be helped to move to a stretcher

  2. Urge her to lie on her left side during transport to prevent supine hypotension syndrome

  3. Ensure additional safety by raising the side rails

  4. Cover her with a blanket or sheet to avoid her feeling chilled

  5. Check that her identification is secure before she leaves the patient unit

  6. Make certain her chart or electronic record remains secure and will be available to OR personnel
• Role of the Support Person

  • In most instances, a woman's family can be as involved in a cesarean birth as they would be for a vaginal birth
  • A support person may need more encouragement to watch a cesarean than a vaginal birth because he or she may believe the surgery will be much bloodier than it actually is
  • Helping family members realize cesarean birth is little different from vaginal birth not only allows them to stay with a woman during the procedure but also helps them progress to bonding with the infant and incorporating the new member into their family more easily
• Pre-op for D&C

  1. Doctor will explain the procedure and offer you the opportunity to ask any questions about the procedure

  2. Sign a consent form for the procedure

  3. Complete medical history, physical examination. You may undergo blood tests or other diagnostic tests

  4. NPO post-midnight or atleast 8 hours before the procedure

  5. Notify for allergies to any medications, iodine, latex, tape, and anesthetic agents (local and general)

  6. Notify of all medications (prescribed and over-the-counter) and herbal supplements that patient is taking

  7. Notify for history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting

  8. If a sedative is given before the procedure, you will need someone to drive you home afterwards when on OPD or clinic

  9. To bring a sanitary napkin to wear after the procedure and other specific preparation as needed
• Documentation

  1. Documentation of nursing care up until the time a woman leaves the nursing care unit or labor room must be completed before a woman leaves for the surgical suite

  2. A preoperative checklist is used as a reminder of all necessary measures to be taken. Checking and signing such form indicates that the specific measures were completed
• Sample pre-op charting for D&C and CS is provided
• To operating room per stretcher accompanied by RN Cruz and transport aide with ongoing 1st D5LRs 1 liter at 30gtts per minute infusing well at left arm at 750 mL level
• Student's complete Name & signature / CI's complete Name & Signature SLU - BSN 2 (group no.) License No.
• Administration of Anesthesia

  1. Surgical nurse will assist a woman to move from the transport stretcher or bed to the OR table and will remain with her while anesthesia is administered

  2. If the woman has an epidural catheter in place from labor, be careful not to dislodge it while she is being moved

  3. During transport and while in surgery, encourage the woman to remain on her side, or place a pillow under her right hip to keep her body slightly tilted to the side, to prevent supine hypotension syndrome

  4. If a spinal anesthetic is to be administered, the anesthesiologist usually will do this with the woman sitting up

  5. The anesthesiologist may then ask you to help the woman curve her back to separate the vertebrae and facilitate entry of the spinal needle

  6. Talking to her while letting her lean against you is the most effective means of helping her maintain this position

  7. Epidural anesthesia is usually administered with the woman lying on her side

  8. Duramorph is a form of morphine commonly used in addition to a local anesthesia in epidurals, its effect lasts up to 24 hours, but because it can cause late occurring respiratory depression, respirations should be assessed every 2 hours post-surgery, continuous pulse oximetry must be used for 24 hours
• Skin Preparation

  1. Shaving away abdominal hair, if indicated, and washing the skin area over the incision site with soap and water

  2. To avoid being shaved, some women who are scheduled for a planned cesarean birth have a bikini wax done 3 or 4 days before surgery
• Surgical Incision

  1. A woman is positioned with a towel under her right hip to move abdominal contents away from the surgical field and to lift her uterus off the vena cava

  2. A screen is placed at her shoulder level and covered with a sterile drape to block the flow of bacteria from her respiratory tract to the incision site

  3. The incision area on the woman's abdomen is then scrubbed with an antiseptic such as iodine, and appropriate drapes are placed around the area so that only a small area of skin is left exposed

  4. Sponge and instrument counts are simplified by the use of prepackaged cesarean birth components

  5. Prepare the woman and support person for the sights they might see, or help talk them through them as they occur
• Classic cesarean incision

  The incision is made vertically through both the abdominal skin and the uterus, it leaves a wide skin scar and also runs through the active contractile portion of the uterus, because this type of scar could rupture during labor, if this type of incision is used, it is likely that a woman will not be able to have a subsequent vaginal birth
• Low segment incision

  Commonly referred to as a low transverse or Pfannenstiel incision, is one made horizontally across the abdomen just over the symphysis pubis and also horizontally across the uterus just over the cervix, this is the most common type of cesarean incision used today, it is also referred to as a Misgav-Ladach or a "bikini" incision, because even a low-cut bathing suit will cover the scar, it is less likely to rupture in subsequent labors, making it possible for a woman to have a vaginal birth after cesarean (VBAC) with a future pregnancy, it also results in less blood loss, is easier to suture, decreases postpartal uterine infections, and is less likely to cause postpartum gastrointestinal complications, the major disadvantage is that it takes longer to perform, possibly making it impractical for an emergent cesarean birth
• Birth of the Infant

  Once the surgical incision is complete, the uterus is then cut and the child's head is born manually, the mouth and nose of the baby may be suctioned by a bulb syringe, before the remainder of the child is born, oxytocin is administered via IV by the anesthesiologist as the child or placenta is delivered, to increase uterine contraction and reduce blood loss, the uterus is pulled forward onto the abdomen and covered with moist gauze, the internal cavity of the uterus is then inspected, and the membranes and placenta manually removed, the uterus, subcutaneous tissues, and skin incisions are then closed
• Introduction of the Newborn

  Once it is determined the newborn is breathing spontaneously, he or she is shown to the mother and support person, both the support person and the mother may hold the baby immediately, women are able to breastfeed after cesarean births the same as after vaginal births, however, initial breastfeeding may be delayed until the woman has been moved to a recovery room along with her infant because breastfeeding initiates uterine contractions, which could interfere with suture placement
• During the D&C procedure

  Remove clothing and change to patient gown, instructed to empty your bladder, positioned on operating or examination table, with your feet and legs supported as for a pelvic examination, an intravenous (IV) line may be started, a urinary catheter may be inserted, your doctor will insert an instrument called a speculum into your vagina to spread the walls of the vagina apart to expose the cervix, your cervix may be cleansed with an antiseptic solution, for local anesthesia, the doctor may numb the area using a small needle to inject medication, if general or regional anesthesia is used, the anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during surgery, a type of forceps, called a tenaculum, may be used to hold the cervix steady for the procedure, the inside of the cervical canal may be scraped with a small curette if the cervical tissue needs to be examined, a thin, rod-like instrument, called a uterine sound, may be inserted through the cervical opening to determine the length of the uterus, the cervix will be dilated by inserting a series of thin rods, the curette will be inserted through the cervical opening into the uterus and the sharp spoon-shaped edges will be passed across the lining of the uterus to scrape away the tissues, the instruments will be removed, any tissues collected with the procedure will be sent to the lab for examination
• Post Partal Care Concerns

  Pain and comfort - Women who have a cesarean birth develop an additional care concern in the immediate postpartal period because they are not only postpartal patients but postsurgical ones, in addition to afterpains from their contracting uterus, they have postsurgical incision pain, a goal of nursing care should be to help women bond successfully with their new infant
• Pain Management

  1. Patient-Controlled Analgesia - Doses of IV narcotic analgesia, such as morphine, to themselves by means of an IV line as needed

  2. Epidural Analgesia - Morphine (Duramorph) or fentanyl added to the epidural catheter immediately after surgery, a technique that keeps them pain free for the next 24 hours

  3. Transcutaneous Electrical Nerve Stimulation - Small electrodes are attached to the woman's skin near her incision; when she feels pain, she pushes a transformer button, the use of TENS can provide important pain relief after a cesarean birth because it gives a
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• Patient-controlled epidural analgesia (PCEA)

  • Effective means of relieving pain
  • Omits the problem of infiltration of an IV infusion, which can occur with IV PCA
• Transcutaneous electrical nerve stimulation (TENS)


  The transmission of an electrical current across the skin
• How TENS works

  1. Small electrodes are attached to the woman's skin near her incision

  2. When she feels pain, she pushes a transformer button

  3. Irritation or stimulation of large afferent nerve fibers by the electrical stimulation block the ability of the smaller, pain-carrying nerve fibers to transmit impulses
• Use of TENS


  • Provides important pain relief after a cesarean birth
  • Gives a woman a sense of control over her situation
• Sources of bleeding for a post Caesarean birth include vaginally from a noncontracted uterus or internally from blood vessels not yet securely closed
• Signs of bleeding

  • Falling blood pressure (more than 20 mmHg systolic)
  • Systolic blood pressure less than 80 mmHg
  • Drop of 5 to 10 mmHg in blood pressure over several readings
  • Change in pulse rate (greater than 110 beats/min or less than 60 beats/min)
  • Respirations more rapid and distressed from previous readings
  • Restlessness and a sense of thirst
• Management of bleeding

  1. Inspect the dressing over the woman's surgical incision for blood staining each time vital signs are assessed

  2. Observe the perineal pad for lochia flow, and palpate the fundal height each time to document uterine contraction

  3. Oxytocin may be prescribed to be added to the first 1 or 2 L of IV fluid after surgery to ensure firm uterine contraction

  4. Watch out for minimal but continued change in vital signs

  5. Assess a woman's uterus for firmness, assess the remainder of her abdomen for softness
• It takes approximately 24 to 48 hours before full peristaltic function is restored and oral intake is possible
• Assessment of bowel elimination

  • First bowel movement following surgery
  • Pain
  • Fluid intake and output
  • Food intake
  • Bowel sounds
  • Passage of flatus
• Management of constipation

  1. Stool softener

  2. Suppository

  3. Enema to facilitate stool evacuation

  4. Drink fluids

  5. Diet high in roughage and fluid

  6. Attempt to move their bowels at least every other day

  7. Caution not to strain to pass stools
• Voiding after surgery provides evidence the woman has adequate renal and circulatory function, because the kidneys must have adequate blood flow through them to function